MEDICAID PHARMACY PRIOR AUTHORIZATION ADVISORY COMMITTEE Recommendations Summary November 7, 2018

Home , Desonide, Diflorasone, Fluocinolone

In Attendance:

Committee Member Yes or No

1 Rosanne Barber Yes

2 Catherine Decker, PharmD Yes

3 John Fangman, M.D. No

4 Kevin Izard, M.D. Yes – arrived @ 11:30am

5 Steve Maike, RPh Yes

6 William E. Raduege, M.D. Yes

7 Robert Rohloff, M.D. Yes

8 Pat Towers Yes

9 Alicia Walker, PharmD Yes

10 Michael Witkovsky, M.D. Yes – arrived @ 9:30am

NOVEMBER 2018 THERAPEUTIC DRUG CLASSES

ALZHEIMER'S AGENTS ANTICONVULSANTS ANTIDEPRESSANTS, OTHER ANTIDEPRESSANTS, SSRIs ANTIHISTAMINES, MINIMALLY SEDATING ANTIHYPERTENSIVES, SYMPATHOLYTIC ANTIHYPERURICEMICS, ORAL ANTIPARKINSON'S AGENTS ANTIPSORIATICS, ORAL ANTIPSORIATICS, TOPICAL ANTIPSYCHOTICS ANXIOLYTICS BILE SALTS BRONCHODILATORS, BETA AGONIST COPD AGENTS COUGH AND COLD/NARCOTICS CYTOKINE AND CAM ANTAGONISTS EPINEPHRINE, SELF-INJECTED ERYTHROPOIESIS STIMULATING PROTEINS GLUCOCORTICOIDS, INHALED GLUCOCORTICOIDS, ORAL HISTAMINE II RECEPTOR BLOCKERS IMMUNOMODULATORS FOR ATOPIC DERMATITIS IMMUNOMODULATORS, TOPICAL INTRANASAL RHINITIS AGENTS LEUKOTRIENE MODIFIERS METHOTREXATE NEUROPATHIC PAIN (ANALGESICS/ANESTHETICS TOPICAL AND FIBROMYALGIA) NSAIDS OPHTHALMIC ANTIBIOTIC/STEROID COMBINATIONS OPHTHALMIC ANTIBIOTICS OPHTHALMIC ANTIINFLAMMATORIES OPHTHALMIC ANTIINFLAMMATORIES/IMMUNOMODULATORS OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS OPHTHALMICS, GLAUCOMA AGENTS OTIC ANTIBIOTICS OTIC ANTI-INFECTIVES SEDATIVE HYPNOTICS STEROIDS, TOPICAL-HIGH POTENCY STEROIDS, TOPICAL-LOW POTENCY STEROIDS, TOPICAL-MEDIUM POTENCY STEROIDS, TOPICAL-VERY HIGH POTENCY STIMULANTS AND RELATED AGENTS

Public Comment Session:

During the Public Comment session, 22 individuals representing drug manufacturers, members of the medical community, and advocates provided in-person presentations on specific drugs or drug classes under review in the meeting.

There was conversation about Prior Authorization (PA) processes and procedures during this session, including but not limited to the availability of Emergency Supply and Expedited Emergency Supply for particular drugs. The Department noted that updated Prior Authorization (PA) procedures are communicated in ForwardHealth Updates published which detail changes to the Preferred Drug List. The Department will include reminders of PA policies, including Emergency Supply and Expedited Emergency Supply, in the upcoming ForwardHealth Update.

Recommendations Summary:

The following 23 drug classes presented for review had no recommended status changes since the November 8, 2017 Wisconsin Medicaid Pharmacy PA Advisory Committee (PAC) meeting and were approved by the PAC in a block vote. The PAC had no additional discussion regarding these drug classes. Drug Classes included in the committee block vote:

 Antidepressants, Other  Antihistamines, Minimally Sedating  Antihypertensives, Sympatholytic  Antihyperuricemics, Oral  Antipsoriatics, Oral  Antipsoriatics, Topical  Anxiolytics  Bile Salts  Bronchodilators, Beta Agonist  Cough And Cold/Narcotics  Histamine II Receptor Blockers  Immunomodulators For Atopic Dermatitis  Immunomodulators, Topical  Leukotriene Modifiers  Methotrexate  NSAIDS  Ophthalmic Antibiotic/Steroid Combinations  Ophthalmic Antibiotics  Ophthalmics For Allergic Conjunctivitis  Ophthalmic Anti-Inflammatories  Otic Anti-Infectives  Otic Antibiotics  Sedative Hypnotics

 Discussion: None  Kevin Izard made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid ALZHEIMER'S AGENTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS MEMANTINE TABLET (AG) (ORAL) 0.3% ON Yes-Gen DONEPEZIL TABLET (ORAL) 58.6% ON Yes-Gen MEMANTINE TABLET (ORAL) 32.2% ON Yes-Gen DONEPEZIL ODT (ORAL) 0.4% ON Yes-Gen MEMANTINE TABLET DOSE PACK (AG) (ORAL) 0.3% ON Yes-Gen GALANTAMINE TABLET (ORAL) 0.4% OFF No-Gen RIVASTIGMINE CAPSULES (ORAL) 2.1% ON Yes-Gen DONEPEZIL 23 MG (ORAL) 0.3% OFF No-Gen EXELON (TRANSDERM.) 2.3% ON Yes GALANTAMINE ER (ORAL) 0.3% OFF No-Gen RIVASTIGMINE (AG) (TRANSDERM.) 0.0% OFF No-Gen NAMENDA XR (ORAL) 0.8% OFF No MEMANTINE ER (ORAL) 1.3% NR No-Gen RIVASTIGMINE (TRANSDERM.) 0.0% OFF No-Gen NAMZARIC (ORAL) 0.5% OFF No GALANTAMINE SOLUTION (ORAL) 0.0% OFF No-Gen NAMZARIC DOSE PACK (ORAL) 0.0% OFF No MEMANTINE SOLUTION (ORAL) 0.2% ON Yes-Gen

 Discussion: None  Robert Rohloff made a motion to accept staff recommendations as presented. o Second – Alicia Walker o All members were in favor of the motion o Motion passes

Wisconsin Medicaid ANTICONVULSANTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS CLONAZEPAM (ORAL) 20.3% ON Yes-Gen PHENOBARBITAL TABLET (ORAL) 0.8% ON Yes-Gen CLONAZEPAM ODT (ORAL) 0.2% OFF No-Gen PHENOBARBITAL ELIXIR (ORAL) 0.3% ON Yes-Gen DIAZEPAM DEVICE (AG) (RECTAL) 0.0% OFF Yes-Gen DIAZEPAM (AG) (RECTAL) 0.0% OFF Yes-Gen DIASTAT ACUDIAL (RECTAL) 0.4% ON No DIASTAT (RECTAL) 0.0% ON No TEGRETOL SUSPENSION (ORAL) 0.1% ON Yes TEGRETOL TABLET (ORAL) 1.3% ON Yes OXCARBAZEPINE TABLETS (ORAL) 3.5% ON Yes-Gen CARBAMAZEPINE TABLET (ORAL) 0.1% OFF No-Gen CARBAMAZEPINE CHEWABLE TABLET (ORAL) 0.5% ON Yes-Gen EQUETRO (ORAL) 0.0% OFF No CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL) 1.0% ON Yes-Gen CARBAMAZEPINE XR (ORAL) 0.0% OFF Yes-Gen CARBAMAZEPINE XR (AG) (ORAL) 0.0% OFF Yes-Gen CARBAMAZEPINE SUSPENSION (ORAL) 0.0% OFF No-Gen OXCARBAZEPINE SUSPENSION (ORAL) 0.7% ON Yes-Gen TEGRETOL XR (ORAL) 0.7% ON No OXTELLAR XR (ORAL) 0.1% OFF No TRILEPTAL SUSPENSION (ORAL) 0.0% OFF No APTIOM (ORAL) 0.1% OFF No 4

Anticonvulsants cont.

PRIMIDONE (AG) (ORAL) 0.0% NR Yes-Gen FELBATOL SUSPENSION (ORAL) 0.0% OFF No FELBATOL TABLET (ORAL) 0.1% OFF No DIVALPROEX TABLET (ORAL) 4.6% ON Yes-Gen PRIMIDONE (ORAL) 1.0% ON Yes-Gen CELONTIN (ORAL) 0.0% ON Yes VALPROIC ACID SOLUTION (ORAL) 0.9% ON Yes-Gen DIVALPROEX SPRINKLE (AG) (ORAL) 0.0% ON Yes-Gen VALPROIC ACID CAPSULE (ORAL) 0.2% ON Yes-Gen DIVALPROEX ER (ORAL) 6.5% ON Yes-Gen PHENYTOIN SUSPENSION (ORAL) 0.1% ON Yes-Gen PHENYTOIN CAPSULE (ORAL) 1.0% ON Yes-Gen PEGANONE (ORAL) 0.0% ON Yes PHENYTOIN CHEWABLE TABLET (ORAL) 0.1% ON Yes-Gen PHENYTOIN EXT CAPSULE (GENERIC PHENYTEK) (ORAL) 0.1% ON Yes-Gen PHENYTEK (ORAL) 0.0% OFF No ETHOSUXIMIDE CAPSULE (AG) (ORAL) 0.0% ON Yes-Gen ETHOSUXIMIDE SYRUP (ORAL) 0.2% ON Yes-Gen DIVALPROEX SPRINKLE (ORAL) 1.3% ON Yes-Gen ETHOSUXIMIDE CAPSULE (ORAL) 0.3% ON Yes-Gen DILANTIN INFATAB (ORAL) 0.0% ON Yes FELBAMATE TABLET (ORAL) 0.3% ON Yes-Gen FELBAMATE SUSPENSION (ORAL) 0.2% ON Yes-Gen TOPIRAMATE ER (QUDEXY) (AG) (ORAL) 0.0% OFF No-Gen LAMOTRIGINE TABLET (ORAL) 20.5% ON Yes-Gen TOPIRAMATE TABLETS (ORAL) 14.0% ON Yes-Gen LEVETIRACETAM TABLETS (ORAL) 7.9% ON Yes-Gen ZONISAMIDE (ORAL) 1.8% ON Yes-Gen LEVETIRACETAM SOLUTION (ORAL) 2.7% ON Yes-Gen LAMOTRIGINE CHEWABLE TABLET (ORAL) 0.4% ON Yes-Gen LAMICTAL TABLET DOSE PACK (ORAL) 0.0% ON Yes LEVETIRACETAM ER (ORAL) 0.6% ON Yes-Gen TOPIRAMATE SPRINKLE (ORAL) 0.4% ON Yes-Gen SABRIL POWDER PACK (ORAL) 0.1% OFF No SABRIL TABLET (ORAL) 0.0% OFF No GABITRIL (ORAL) 0.0% ON Yes QUDEXY XR (ORAL) 0.0% OFF No LAMICTAL ODT DOSE PACK (ORAL) 0.0% OFF No BANZEL TABLET (ORAL) 0.2% OFF No LAMOTRIGINE XR (ORAL) 0.7% OFF No-Gen VIMPAT SOLUTION (ORAL) 0.2% OFF No VIMPAT TABLET (ORAL) 1.1% OFF No LAMOTRIGINE ODT DOSE PACK (ORAL) 0.0% OFF No-Gen LAMICTAL ODT (ORAL) 0.0% OFF No FYCOMPA TABLET (ORAL) 0.1% OFF No ONFI TABLET (ORAL) 0.8% OFF No TROKENDI XR (ORAL) 0.2% OFF No LAMICTAL XR (ORAL) 0.1% OFF No LAMOTRIGINE TABLET DOSE PACK (ORAL) 0.0% ON Yes-Gen LAMOTRIGINE ODT (ORAL) 0.1% OFF No-Gen TIAGABINE (ORAL) 0.0% OFF No-Gen BANZEL SUSPENSION (ORAL) 0.0% OFF No SPRITAM (ORAL) 0.0% OFF No ONFI SUSPENSION (ORAL) 0.4% OFF No FYCOMPA SUSPENSION (ORAL) 0.0% OFF No LAMICTAL XR DOSE PACK (ORAL) 0.0% OFF No BRIVIACT TABLET (ORAL) 0.1% OFF No BRIVIACT SOLUTION (ORAL) 0.0% OFF No VIGABATRIN POWDER PACK (ORAL) 0.0% OFF No-Gen

 Discussion: Rachel Currans-Henry stated that during the closed session, the Committee discussed Emergency Supply and Expedited Emergency Supply policies for this class. The State will publish reminders of these policies in the ForwardHealth Update to ensure providers are aware of their availability and processes.

 Michael Witkovsky made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid ANTIDEPRESSANTS, SSRIs

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS CITALOPRAM TABLET (ORAL) 12.2% ON Yes-Gen FLUOXETINE CAPSULE (ORAL) 24.7% ON Yes-Gen SERTRALINE TABLET (ORAL) 34.7% ON Yes-Gen ESCITALOPRAM TABLET (ORAL) 17.3% ON Yes-Gen PAROXETINE TABLET (ORAL) 8.7% ON Yes-Gen FLUOXETINE SOLUTION (ORAL) 0.7% ON Yes-Gen FLUVOXAMINE (ORAL) 0.9% ON Yes-Gen PEXEVA (ORAL) 0.0% OFF No CITALOPRAM SOLUTION (ORAL) 0.1% ON Yes-Gen FLUOXETINE TABLET (ORAL) 0.2% OFF No-Gen BRISDELLE (ORAL) 0.0% OFF No SERTRALINE CONC (ORAL) 0.3% ON Yes-Gen FLUOXETINE 60 MG (ORAL) 0.0% OFF No-Gen SARAFEM (ORAL) 0.0% OFF No PAROXETINE CR (ORAL) 0.1% OFF No-Gen ESCITALOPRAM SOLUTION (ORAL) 0.1% ON Yes-Gen PAROXETINE (BRISDELLE) (AG) (ORAL) 0.0% NR No-Gen PAROXETINE (BRISDELLE) (ORAL) 0.0% NR No-Gen FLUOXETINE CAPSULE DR (ORAL) 0.0% OFF No-Gen PAXIL SUSPENSION (ORAL) 0.0% ON Yes FLUVOXAMINE ER (ORAL) 0.0% OFF No-Gen

 Discussion: None  Catherine Decker made a motion to accept staff recommendations as presented. o Second – Michael Witkovsky o All members were in favor of the motion o Motion passes

Wisconsin Medicaid ANTIPARKINSON'S AGENTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS AZILECT (ORAL) 0.0% OFF No PRAMIPEXOLE (ORAL) 16.5% ON Yes-Gen ROPINIROLE (ORAL) 29.0% ON Yes-Gen TRIHEXYPHENIDYL TABLET (ORAL) 5.0% ON Yes-Gen BENZTROPINE (ORAL) 31.5% ON Yes-Gen AMANTADINE SYRUP (ORAL) 0.2% ON Yes-Gen ZELAPAR (ORAL) 0.0% OFF No CARBIDOPA / LEVODOPA (ORAL) 9.4% ON Yes-Gen CARBIDOPA / LEVODOPA ER (ORAL) 2.0% ON Yes-Gen AMANTADINE CAPSULE (ORAL) 2.8% ON Yes-Gen TRIHEXYPHENIDYL ELIXIR (ORAL) 0.1% ON Yes-Gen NEUPRO (TRANSDERM) 0.3% OFF No SELEGILINE TABLET (ORAL) 0.0% ON Yes-Gen SELEGILINE CAPSULE (ORAL) 0.1% ON Yes-Gen AMANTADINE TABLET (ORAL) 1.3% ON Yes-Gen CARBIDOPA / LEVODOPA ODT (ORAL) 0.1% ON Yes-Gen ENTACAPONE (ORAL) 0.2% OFF No-Gen ROPINIROLE ER (ORAL) 0.1% OFF No-Gen BROMOCRIPTINE (ORAL) 0.6% ON Yes-Gen STALEVO (ORAL) 0.0% OFF No CARBIDOPA/LEVODOPA/ENTACAPONE (ORAL) 0.2% ON Yes-Gen RASAGILINE (ORAL) 0.2% OFF No-Gen RYTARY (ORAL) 0.1% OFF No CARBIDOPA (ORAL) 0.2% ON Yes-Gen OSMOLEX ER (ORAL) 0.0% NR No PRAMIPEXOLE ER (ORAL) 0.0% OFF No-Gen XADAGO (ORAL) 0.0% OFF No GOCOVRI (ORAL) 0.0% NR No TOLCAPONE (ORAL) 0.0% OFF No-Gen

 Discussion: None  Pat Towers made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid ANTIPSYCHOTICS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS QUETIAPINE ER (AG) (ORAL) 0.1% ON Yes-Gen RISPERIDONE TABLET (ORAL) 15.8% ON Yes-Gen QUETIAPINE TABLETS (ORAL) 27.8% ON Yes-Gen OLANZAPINE TABLET (ORAL) 7.9% ON Yes-Gen ARIPIPRAZOLE TABLET (ORAL) 18.4% ON Yes-Gen OLANZAPINE ODT (ORAL) 0.5% ON Yes-Gen ZIPRASIDONE CAPSULE (ORAL) 4.6% ON Yes-Gen RISPERIDONE SOLUTION (ORAL) 0.4% ON Yes-Gen QUETIAPINE ER (ORAL) 1.2% ON Yes-Gen CLOZAPINE (ORAL) 2.3% ON Yes-Gen RISPERIDONE ODT (ORAL) 0.4% ON Yes-Gen SAPHRIS (SUBLINGUAL) 0.4% OFF No CLOZAPINE ODT (AG) (ORAL) 0.0% OFF No-Gen LATUDA (ORAL) 6.1% ON Yes FANAPT TABLET (ORAL) 0.1% OFF No FAZACLO (ORAL) 0.0% OFF No PALIPERIDONE (AG) (ORAL) 0.0% OFF No-Gen CLOZAPINE ODT (ORAL) 0.2% OFF No-Gen PALIPERIDONE (ORAL) 0.0% OFF No-Gen ARIPIPRAZOLE SOLUTION (ORAL) 0.1% ON Yes-Gen VRAYLAR (ORAL) 1.0% OFF No REXULTI (ORAL) 0.9% OFF No INVEGA (ORAL) 1.2% OFF No ARIPIPRAZOLE ODT (ORAL) 0.0% ON Yes-Gen VERSACLOZ (ORAL) 0.0% OFF No NUPLAZID TABLET (ORAL) 0.0% OFF No NUPLAZID CAPSULE (ORAL) 0.0% NR No SYMBYAX (ORAL) 0.0% OFF No OLANZAPINE/FLUOXETINE (ORAL) 0.0% OFF No-Gen HALOPERIDOL DECANOATE (INJECTION) 0.9% ON Yes-Gen FLUPHENAZINE DECANOATE (INJECTION) 0.3% ON Yes-Gen HALDOL DECANOATE (INTRAMUSC) 0.0% ON Yes RISPERDAL CONSTA (INTRAMUSC.) 0.8% ON Yes ARISTADA INITIO (INTRAMUSC) 0.0% NR Yes INVEGA SUSTENNA (INTRAMUSC) 1.8% ON Yes ZYPREXA RELPREVV (INTRAMUSC) 0.0% ON Yes ARISTADA (INTRAMUSC) 0.5% ON Yes ABILIFY MAINTENA (INTRAMUSC.) 0.9% ON Yes PERSERIS (SUBCUTANEOUS) 0.0% NR No INVEGA TRINZA (INTRAMUSC) 0.2% ON Yes HALOPERIDOL LACTATE CONC (ORAL) 0.0% ON Yes-Gen HALOPERIDOL (ORAL) 2.7% ON Yes-Gen PERPHENAZINE (ORAL) 0.2% ON Yes-Gen LOXAPINE (ORAL) 0.3% ON Yes-Gen TRIFLUOPERAZINE (ORAL) 0.2% ON Yes-Gen FLUPHENAZINE TABLET (ORAL) 0.6% ON Yes-Gen THIORIDAZINE (ORAL) 0.1% OFF No-Gen AMITRIPTYLINE / PERPHENAZINE (ORAL) 0.0% ON Yes-Gen PIMOZIDE (ORAL) 0.0% ON Yes-Gen THIOTHIXENE (ORAL) 0.2% ON Yes-Gen CHLORPROMAZINE (ORAL) 0.6% ON Yes-Gen FLUPHENAZINE ELIXIR/SOLN (ORAL) 0.0% ON Yes-Gen ADASUVE (INHALATION) 0.0% OFF No

 Discussion: None  Kevin Izard made a motion to accept staff recommendations as presented. o Second – Michael Witkovsky o All members were in favor of the motion o Motion passes

Wisconsin Medicaid COPD AGENTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS SPIRIVA (INHALATION) 47.0% ON Yes TUDORZA PRESSAIR (INHALATION) 0.5% OFF No IPRATROPIUM NEBULIZER (INHALATION) 1.6% ON Yes-Gen IPRATROPIUM / ALBUTEROL (INHALATION) 17.7% ON Yes-Gen ATROVENT HFA (INHALATION) 2.9% ON Yes STIOLTO RESPIMAT (INHALATION) 0.9% OFF Yes COMBIVENT RESPIMAT (INHALATION) 20.4% ON Yes BEVESPI AEROSPHERE (INHALATION) 2.0% ON Yes ANORO ELLIPTA (INHALATION) 1.7% OFF No UTIBRON NEOHALER (INHALATION) 0.0% OFF No INCRUSE ELLIPTA (INHALATION) 0.9% OFF No SEEBRI NEOHALER (INHALATION) 0.0% OFF No SPIRIVA RESPIMAT (INHALATION) 2.2% OFF No DALIRESP (ORAL) 2.2% OFF No LONHALA MAGNAIR (INHALATION) 0.0% NR No

 Discussion: None  Catherine Decker made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid CYTOKINE AND CAM ANTAGONISTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS OTEZLA (ORAL) 6.4% ON Yes ENBREL KIT (INJECTION) 0.7% ON Yes XELJANZ (ORAL) 0.9% OFF No XELJANZ XR (ORAL) 1.5% OFF No ENBREL SYRINGE (INJECTION) 3.3% ON Yes ENBREL PEN (INJECTION) 14.8% ON Yes HUMIRA PEN KIT (INJECTION) 0.0% ON Alternate HUMIRA PEN KIT (INJECTION) 0.0% ON Alternate HUMIRA KIT (INJECTION) 0.0% ON Alternate HUMIRA KIT (INJECTION) 0.0% ON Alternate COSENTYX PEN INJECTER (SUBCUTANE.) 2.4% OFF No HUMIRA PEN KIT (INJECTION) 52.4% ON Yes HUMIRA KIT (INJECTION) 5.7% ON Yes KINERET (INJECTION) 0.5% OFF No ENBREL MINI CARTRIDGE (SUBCUTANE.) 0.1% NR Yes CIMZIA SYRINGE KIT (INJECTION) 2.9% OFF No COSENTYX SYRINGE (SUBCUTANE.) 0.4% OFF No ORENCIA CLICKJECT (SUBCUTANE.) 1.0% OFF No ORENCIA SYRINGE (SUBCUTANE.) 1.2% OFF No SIMPONI PEN INJECTER (INJECTION) 0.6% OFF No KEVZARA PEN (SUBCUTANEOUS) 0.0% NR No ACTEMRA SYRINGE (SUBCUTANE.) 1.6% OFF No TALTZ SYRINGE (SUBCUTANE.) 0.0% OFF No SIMPONI SYRINGE (INJECTION) 0.1% OFF No KEVZARA SYRINGE (SUBCUTANEOUS) 0.3% OFF No OLUMIANT (ORAL) 0.0% NR No TALTZ AUTOINJECTOR (SUBCUTANE.) 0.6% OFF No CIMZIA KIT (INJECTION) 0.1% OFF No SILIQ (SUBCUTANE.) 0.0% OFF No STELARA SYRINGE (INJECTION) 2.0% OFF No TREMFYA (SUBCUTANE.) 0.2% OFF No

 Discussion: Rachel Currans-Henry stated that in closed session written testimony submitted by a provider was discussed, and the Department has reached out to the provider and pharmacy to clarify and resolve the issue.

The Department is modifying the Prior Authorization criteria for preferred products in this class, to be effective January 1, 2019.

 William Raduege made a motion to accept staff recommendations as presented. o Second – Robert Rohloff o All members were in favor of the motion o Motion passes

Wisconsin Medicaid EPINEPHRINE, SELF-INJECTED

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS EPINEPHRINE 0.3 MG (EPIPEN) (AG) (INJECTION) 60.3% ON Yes-Gen EPINEPHRINE 0.15 MG (EPIPEN JR) (AG) (INJECTION) 15.3% ON Yes-Gen EPIPEN (INTRAMUSC) 11.1% ON No EPIPEN JR (INTRAMUSC) 1.9% ON No EPINEPHRINE 0.15 MG (ADRENACLICK) (AG) (INJECTION) 1.2% ON No-Gen EPINEPHRINE 0.3 MG (ADRENACLICK) (AG) (INJECTION) 10.1% ON No-Gen

 Discussion: Catherine Decker inquired about whether or not this class includes the dual packs. Rick Pope from Provider Synergies responded that it does include the dual packs.

 Robert Rohloff made a motion to accept staff recommendations as presented. o Second – Pat Towers o All members were in favor of the motion o Motion passes

Wisconsin Medicaid ERYTHROPOIESIS STIMULATING PROTEINS

Current Current PDL Market PDL Recomme COMMITTEE SECRETARY Brand Name Share Status ndation RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS RETACRIT (INJECTION) 0.0% NR Yes EPOGEN (INJECTION) 0.0% OFF No PROCRIT (INJECTION) 33.2% ON Yes ARANESP VIAL (INJECTION) 15.0% ON Yes ARANESP DISP SYRIN (INJECTION) 51.7% ON Yes MIRCERA (INJECTION) 0.0% NR No

 Discussion: None  Michael Witkovsky made a motion to accept staff recommendations as presented. o Second – Roseanne Barber o All members were in favor of the motion o Motion passes

Wisconsin Medicaid GLUCOCORTICOIDS, INHALED

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS ADVAIR DISKUS (INHALATION) 33.2% ON Yes ADVAIR HFA (INHALATION) 0.6% OFF Yes DULERA (INHALATION) 6.4% ON Yes SYMBICORT (INHALATION) 25.5% ON Yes AIRDUO RESPICLICK (INHALATION) 0.0% OFF No BREO ELLIPTA (INHALATION) 1.1% OFF No FLUTICASONE/SALMETEROL (AIRDUO) (AG) (INHALATION) 0.0% OFF No-Gen TRELEGY ELLIPTA (INHALATION) 0.1% NR No ASMANEX (INHALATION) 2.1% ON Yes FLOVENT HFA (INHALATION) 20.2% ON Yes PULMICORT FLEXHALER (INHALATION) 2.4% ON Yes QVAR (INHALATION) 4.0% ON No FLOVENT DISKUS (INHALATION) 0.0% OFF No ARNUITY ELLIPTA (INHALATION) 0.1% OFF No ASMANEX HFA (INHALATION) 0.0% OFF No ARMONAIR RESPICLICK (INHALATION) 0.0% OFF No ALVESCO (INHALATION) 0.1% OFF No AEROSPAN (INHALATION) 0.0% OFF No QVAR REDIHALER (INHALATION) 0.3% NR No PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) 3.3% ON Yes BUDESONIDE 0.25, 0.5 MG RESPULES (INHALATION) 0.1% OFF No-Gen PULMICORT 1 MG RESPULES (INHALATION) 0.4% ON Yes BUDESONIDE 1 MG RESPULES (INHALATION) 0.0% OFF No-Gen

 Discussion: None  Robert Rohloff made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid GLUCOCORTICOIDS, ORAL

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS RAYOS TABLET DR (ORAL) 0.0% OFF No ORAPRED ODT (ORAL) 0.1% ON Yes MEDROL TABLET (ORAL) 0.0% OFF No PREDNISOLONE SOLUTION (ORAL) 3.9% ON Yes-Gen PREDNISONE TABLET (ORAL) 68.7% ON Yes-Gen PREDNISOLONE SODIUM PHOSPHATE (ORAL) 5.0% ON Yes-Gen METHYLPREDNISOLONE TAB DS PK (ORAL) 11.9% ON Yes-Gen DEXAMETHASONE TABLET (ORAL) 4.7% ON Yes-Gen METHYLPREDNISOLONE 4 MG TABLET (ORAL) 0.4% ON Yes-Gen DEXAMETHASONE ELIXIR (ORAL) 0.1% ON Yes-Gen HYDROCORTISONE (ORAL) 2.9% ON Yes-Gen DEXAMETHASONE SOLUTION (ORAL) 0.1% ON Yes-Gen PREDNISONE TAB DS PK (ORAL) 0.0% ON Yes-Gen DEXAMETHASONE INTENSOL (ORAL) 0.3% ON Yes-Gen METHYLPREDNISOLONE 16 MG TABLET (ORAL) 0.0% ON Yes-Gen METHYLPREDNISOLONE 32 MG TABLET (ORAL) 0.1% ON Yes-Gen METHYLPREDNISOLONE 8 MG TABLET (ORAL) 0.0% ON Yes-Gen TAPERDEX (ORAL) 0.0% NR No-Gen PREDNISONE SOLUTION (ORAL) 0.2% ON Yes-Gen MILLIPRED SOLUTION (ORAL) 0.0% OFF No CORTISONE (ORAL) 0.0% OFF No-Gen DEXPAK (ORAL) 0.0% OFF No PREDNISOLONE SODIUM PHOSPHATE SOLUTION (MILLIPRED) (ORAL)0.0% OFF No-Gen PREDNISOLONE SODIUM PHOSPHATE SOLUTION (VERIPRED) (ORAL)0.0% OFF No-Gen PREDNISOLONE SODIUM PHOSPHATE ODT (AG) (ORAL) 0.0% OFF No-Gen PREDNISONE INTENSOL (ORAL) 0.1% ON Yes-Gen PREDNISOLONE SODIUM PHOSPHATE ODT (ORAL) 0.0% OFF No-Gen BUDESONIDE EC (ORAL) 1.4% ON Yes-Gen MILLIPRED DP TAB DS PK (ORAL) 0.0% OFF No MILLIPRED TABLET (ORAL) 0.0% OFF No-Gen DEXAMETHASONE TAB DS PK (ORAL) 0.0% OFF No-Gen EMFLAZA SUSPENSION (ORAL) 0.0% OFF No EMFLAZA TABLET (ORAL) 0.0% OFF No

 Discussion: Pat Towers mentioned that during the closed session, a study related to Emflaza referenced during the morning session was discussed. Rachel Currans-Henry stated the discussion included feedback and perspective from Dr. Julie Sager, Department Medical Director.

 Catherine Decker made a motion to accept staff recommendations as presented. o Second – Roseanne Barber o All members were in favor of the motion o Motion passes

Wisconsin Medicaid INTRANASAL RHINITIS AGENTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS ASTEPRO (NASAL) 0.0% OFF No AZELASTINE (ASTELIN) (NASAL) 1.8% ON Yes-Gen AZELASTINE (ASTEPRO) (AG) (NASAL) 0.0% OFF No-Gen AZELASTINE (ASTEPRO) (NASAL) 0.1% OFF No-Gen OLOPATADINE (AG) (NASAL) 0.8% OFF Yes-Gen OLOPATADINE (NASAL) 0.8% OFF Yes-Gen IPRATROPIUM (NASAL) 2.2% ON Yes-Gen ZETONNA (NASAL) 0.0% OFF No DYMISTA (NASAL) 0.2% OFF No OMNARIS (NASAL) 0.0% OFF No QNASL 80 (NASAL) 0.2% OFF No FLUTICASONE (NASAL) 91.7% ON Yes-Gen BECONASE AQ (NASAL) 1.2% ON Yes QNASL 40 (NASAL) 0.0% OFF No MOMETASONE (AG) (NASAL) 0.1% OFF No-Gen FLUNISOLIDE (NASAL) 0.0% OFF No-Gen MOMETASONE (NASAL) 0.7% OFF No-Gen NASONEX (NASAL) 0.2% OFF No XHANCE (NASAL) 0.0% NR No

 Discussion: None  Catherine Decker made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid NEUROPATHIC PAIN

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS SAVELLA (ORAL) 0.6% ON Yes HORIZANT (ORAL) 0.0% OFF No SAVELLA DOSE PACK (ORAL) 0.0% ON Yes LYRICA CAPSULE (ORAL) 14.0% ON Yes GRALISE (ORAL) 0.0% OFF No CAPSAICIN OTC (TOPICAL) 0.2% ON Yes-Gen GABAPENTIN CAPSULE (ORAL) 41.6% ON Yes-Gen DULOXETINE (CYMBALTA) (ORAL) 22.7% ON Yes-Gen GABAPENTIN TABLET (ORAL) 14.4% ON Yes-Gen ZOSTRIX OTC (TOPICAL) 0.0% ON Yes GABAPENTIN SOLUTION (ORAL) 0.5% ON Yes-Gen LIDOCAINE (TOPICAL) 4.5% ON Yes-Gen LIDOCAINE (AG) (TOPICAL) 1.3% ON Yes-Gen DULOXETINE (IRENKA) (ORAL) 0.0% OFF No-Gen LYRICA SOLUTION (ORAL) 0.0% ON Yes LYRICA CR (ORAL) 0.0% NR No

 Discussion: None  Michael Witkovsky made a motion to accept staff recommendations as presented. o Second – Roseanne Barber o All members were in favor of the motion o Motion passes

Wisconsin Medicaid OPHTHALMICS, ANTI-INFLAMMATORY/IMMUNOMODULATOR

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS RESTASIS (OPHTHALMIC) 82.9% ON Yes RESTASIS MULTIDOSE (OPHTHALMIC) 10.6% ON No XIIDRA (OPHTHALMIC) 6.5% OFF No

 Discussion: None  Kevin Izard made a motion to accept staff recommendations as presented. o Second – Pat Towers o All members were in favor of the motion o Motion passes

Wisconsin Medicaid OPHTHALMICS, GLAUCOMA AGENTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS ALPHAGAN P 0.15% (OPHTHALMIC) 2.2% ON Yes ALPHAGAN P 0.1% (OPHTHALMIC) 0.1% OFF No BRIMONIDINE (OPHTHALMIC) 6.9% ON Yes-Gen IOPIDINE (OPHTHALMIC) 0.0% OFF No APRACLONIDINE (OPHTHALMIC) 0.0% OFF No-Gen BRIMONIDINE P 0.15% (OPHTHALMIC) 0.1% OFF No-Gen TIMOLOL (ISTALOL) (AG) (OPHTHALMIC) 0.0% NR No-Gen BETOPTIC S (OPHTHALMIC) 0.3% ON Yes ISTALOL (OPHTHALMIC) 0.0% OFF No COMBIGAN (OPHTHALMIC) 5.9% ON Yes LEVOBUNOLOL (OPHTHALMIC) 0.5% ON Yes-Gen CARTEOLOL (OPHTHALMIC) 0.1% ON Yes-Gen TIMOLOL (OPHTHALMIC) 14.9% ON Yes-Gen BETAXOLOL (OPHTHALMIC) 0.0% OFF No-Gen TIMOPTIC OCUDOSE (OPHTHALMIC) 0.1% OFF No TIMOLOL (ISTALOL) (OPHTHALMIC) 0.0% NR No-Gen AZOPT (OPHTHALMIC) 3.2% ON Yes SIMBRINZA (OPHTHALMIC) 1.7% ON Yes DORZOLAMIDE / TIMOLOL (OPHTHALMIC) 5.2% ON Yes-Gen DORZOLAMIDE (OPHTHALMIC) 3.1% ON Yes-Gen DORZOLAMIDE/TIMOLOL/PF DROPS (OPHTHALMIC) 0.0% OFF No-Gen COSOPT PF (OPHTHALMIC) 0.2% OFF No PILOCARPINE (OPHTHALMIC) 0.4% ON Yes-Gen LUMIGAN 5ML (OPHTHALMIC) 0.1% OFF No TRAVATAN Z 5 ML (OPHTHALMIC) 1.6% ON Yes LUMIGAN 2.5ML (OPHTHALMIC) 0.8% OFF No TRAVATAN Z 2.5 ML (OPHTHALMIC) 14.0% ON Yes LATANOPROST 2.5 ML (OPHTHALMIC) 38.2% ON Yes-Gen ZIOPTAN (OPHTHALMIC) 0.2% OFF No BIMATOPROST 2.5ML (OPHTHALMIC) 0.0% OFF No-Gen VYZULTA (OPHTHALMIC) 0.0% NR No BIMATOPROST 5ML (OPHTHALMIC) 0.0% OFF No-Gen BIMATOPROST 7.5ML (OPHTHALMIC) 0.0% OFF No-Gen RHOPRESSA (OPHTHALMIC) 0.0% NR No

 Discussion: None  William Raduege made a motion to accept staff recommendations as presented. o Second – Robert Rohloff o All members were in favor of the motion o Motion passes

Wisconsin Medicaid STEROIDS, TOPICAL HIGH

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS TRIAMCINOLONE ACETONIDE CREAM (TOPICAL) 52.2% ON Yes-Gen BETAMET DIPROP / PROP GLY CREAM (TOPICAL) 0.0% OFF No-Gen TRIAMCINOLONE ACETONIDE OINTMENT (TOPICAL) 35.8% ON Yes-Gen TRIAMCINOLONE ACETONIDE LOTION (TOPICAL) 1.5% ON Yes-Gen BETAMETHASONE DIPROPIONATE LOTION (TOPICAL) 0.1% OFF No-Gen BETAMETHASONE VALERATE OINTMENT (TOPICAL) 4.0% ON Yes-Gen BETAMETHASONE VALERATE CREAM (TOPICAL) 3.9% ON Yes-Gen BETAMETHASONE VALERATE LOTION (TOPICAL) 1.6% ON Yes-Gen FLUOCINONIDE SOLUTION (TOPICAL) 0.2% OFF No-Gen KENALOG AEROSOL (TOPICAL) 0.0% OFF No BETAMETHASONE DIPROPIONATE CREAM (TOPICAL) 0.1% OFF No-Gen FLUOCINONIDE OINTMENT (TOPICAL) 0.3% OFF No-Gen BETAMETHASONE DIPROPIONATE OINTMENT (TOPICAL) 0.0% OFF No-Gen FLUOCINONIDE EMOLLIENT (TOPICAL) 0.0% OFF No-Gen BETAMET DIPROP / PROP GLY OINTMENT (TOPICAL) 0.1% OFF No-Gen FLUOCINONIDE CREAM (TOPICAL) 0.2% OFF No-Gen FLUOCINONIDE GEL (TOPICAL) 0.0% OFF No-Gen HALOG CREAM (TOPICAL) 0.0% OFF No HALOG OINTMENT (TOPICAL) 0.0% OFF No BETAMETHASONE DIPROPIONATE GEL (TOPICAL) 0.0% OFF No-Gen BETAMET DIPROP / PROP GLY LOTION (TOPICAL) 0.0% OFF No-Gen DESOXIMETASONE OINTMENT (TOPICAL) 0.1% OFF No-Gen DESOXIMETASONE CREAM (TOPICAL) 0.1% OFF No-Gen TOPICORT OINTMENT (TOPICAL) 0.0% OFF No DIPROLENE OINTMENT (TOPICAL) 0.0% OFF No AMCINONIDE LOTION (TOPICAL) 0.0% OFF No-Gen TRIAMCINOLONE ACETONIDE AEROSOL (TOPICAL) 0.0% OFF No-Gen DESOXIMETASONE GEL (TOPICAL) 0.0% OFF No-Gen DIFLORASONE DIACETATE OINTMENT (TOPICAL) 0.0% OFF No-Gen SERNIVO SPRAY (TOPICAL) 0.0% OFF No DESOXIMETASONE SPRAY (TOPICAL) 0.0% NR No-Gen TOPICORT SPRAY (TOPICAL) 0.0% OFF No DIFLORASONE DIACETATE CREAM (TOPICAL) 0.0% OFF No-Gen TRIANEX OINTMENT (TOPICAL) 0.0% OFF No-Gen AMCINONIDE CREAM (TOPICAL) 0.0% OFF No-Gen

 Discussion: None  Robert Rohloff made a motion to accept staff recommendations as presented. o Second – Michael Witkovsky o All members were in favor of the motion o Motion passes

Wisconsin Medicaid STEROIDS, TOPICAL LOW

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS CAPEX SHAMPOO (TOPICAL) 0.0% OFF No DERMA-SMOOTHE-FS (TOPICAL) 0.0% OFF Yes HYDROCORTISONE CREAM OTC (TOPICAL) 6.6% ON Yes-Gen HYDROCORTISONE OINTMENT OTC (TOPICAL) 1.0% ON Yes-Gen SCALPICIN OTC (TOPICAL) 0.0% ON Yes-Gen HYDROCORTISONE LOTION OTC (TOPICAL) 0.3% ON Yes-Gen HYDROCORTISONE CREAM (TOPICAL) 43.8% ON Yes-Gen HYDROCORTISONE OINTMENT (TOPICAL) 42.8% ON Yes-Gen HYDROCORTISONE LOTION (TOPICAL) 1.4% ON Yes-Gen DESONATE GEL (TOPICAL) 0.0% OFF No ALCLOMETASONE DIPROPIONATE OINTMENT (TOPICAL) 0.0% OFF No-Gen ALCLOMETASONE DIPROPIONATE CREAM (TOPICAL) 0.0% OFF No-Gen DESONIDE CREAM (TOPICAL) 0.2% OFF No-Gen FLUOCINOLONE 0.01% OIL (TOPICAL) 3.7% ON No-Gen TEXACORT (TOPICAL) 0.0% OFF No DESONIDE OINTMENT (TOPICAL) 0.1% OFF No-Gen DESONIDE LOTION (TOPICAL) 0.0% OFF No-Gen HYDROCORTISONE / MIN OIL / PET OINTMENT (TOPICAL) 0.0% ON No-Gen

 Discussion: None  Pat Towers made a motion to accept staff recommendations as presented. o Second – William Raduege o All members were in favor of the motion o Motion passes

Wisconsin Medicaid STEROIDS, TOPICAL MEDIUM

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS MOMETASONE FUROATE SOLUTION (TOPICAL) 6.3% ON Yes-Gen MOMETASONE FUROATE OINTMENT (TOPICAL) 27.7% ON Yes-Gen FLUTICASONE PROPIONATE OINTMENT (TOPICAL) 12.5% ON Yes-Gen FLUTICASONE PROPIONATE CREAM (TOPICAL) 32.2% ON Yes-Gen MOMETASONE FUROATE CREAM (TOPICAL) 19.9% ON Yes-Gen SYNALAR OINTMENT (TOPICAL) 0.0% OFF No FLUOCINOLONE ACETONIDE CREAM (TOPICAL) 0.0% OFF No-Gen PREDNICARBATE OINTMENT (TOPICAL) 0.0% OFF No-Gen FLUOCINOLONE ACETONIDE OINTMENT (TOPICAL) 0.1% OFF No-Gen FLUOCINOLONE ACETONIDE SOLUTION (TOPICAL) 0.4% OFF No-Gen HYDROCORTISONE BUTYRATE CREAM (AG) (TOPICAL) 0.0% OFF No-Gen SYNALAR SOLUTION (TOPICAL) 0.0% OFF No HYDROCORTISONE VALERATE CREAM (TOPICAL) 0.1% OFF No-Gen PREDNICARBATE CREAM (TOPICAL) 0.0% OFF No-Gen HYDROCORTISONE BUTYRATE CREAM (TOPICAL) 0.1% OFF No-Gen PANDEL (TOPICAL) 0.0% OFF No HYDROCORTISONE VALERATE OINTMENT (TOPICAL) 0.1% OFF No-Gen HYDROCORTISONE BUTYRATE OINTMENT (TOPICAL) 0.1% OFF No-Gen CLOCORTOLONE CREAM (AG) (TOPICAL) 0.1% OFF No-Gen HYDROCORTISONE BUTYRATE SOLUTION (AG) (TOPICAL) 0.0% OFF No-Gen CLODERM (TOPICAL) 0.1% OFF No HYDROCORTISONE BUTYRATE SOLUTION (TOPICAL) 0.0% OFF No-Gen BETAMETHASONE VALERATE FOAM (TOPICAL) 0.4% OFF No-Gen HYDROCORTISONE BUTYRATE/EMOLLIENT (AG) (TOPICAL) 0.0% OFF No-Gen FLUTICASONE PROPIONATE LOTION (TOPICAL) 0.1% OFF No-Gen HYDROCORTISONE BUTYRATE/EMOLLIENT (TOPICAL) 0.0% OFF No-Gen HYDROCORTISONE BUTYRATE LOTION (TOPICAL) 0.0% NR No-Gen FLURANDRENOLIDE OINTMENT (TOPICAL) 0.0% OFF No-Gen HYDROCORTISONE BUTYRATE LOTION (AG) (TOPICAL) 0.0% NR No-Gen LUXIQ (TOPICAL) 0.1% OFF No CORDRAN TAPE (TOPICAL) 0.1% OFF No FLURANDRENOLIDE CREAM (TOPICAL) 0.0% OFF No-Gen FLURANDRENOLIDE LOTION (AG) (TOPICAL) 0.0% OFF No-Gen FLURANDRENOLIDE LOTION (TOPICAL) 0.0% OFF No-Gen

 Discussion: None  William Raduege made a motion to accept staff recommendations as presented. o Second – Robert Rohloff o All members were in favor of the motion o Motion passes

Wisconsin Medicaid STEROIDS, TOPICAL VERY HIGH

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS CLOBEX SPRAY (TOPICAL) 0.0% OFF No CLOBEX SHAMPOO (TOPICAL) 1.3% ON Yes CLOBEX LOTION (TOPICAL) 0.2% ON Yes CLOBETASOL PROPIONATE SOLUTION (TOPICAL) 22.1% ON Yes-Gen CLOBETASOL PROPIONATE CREAM (TOPICAL) 26.3% ON Yes-Gen CLOBETASOL PROPIONATE OINTMENT (TOPICAL) 40.4% ON Yes-Gen HALOBETASOL PROPIONATE CREAM (TOPICAL) 1.0% ON Yes-Gen CLOBETASOL PROPIONATE GEL (TOPICAL) 1.6% ON Yes-Gen CLOBETASOL EMOLLIENT (TOPICAL) 1.7% ON Yes-Gen HALOBETASOL PROPIONATE OINTMENT (TOPICAL) 3.5% ON Yes-Gen CLOBETASOL PROPIONATE FOAM (TOPICAL) 1.4% ON No-Gen CLOBETASOL SHAMPOO (TOPICAL) 0.1% OFF No-Gen CLOBETASOL PROPIONATE SPRAY (AG) (TOPICAL) 0.2% OFF No-Gen CLOBETASOL LOTION (TOPICAL) 0.0% OFF No-Gen CLOBETASOL PROPIONATE SPRAY (TOPICAL) 0.1% OFF No-Gen APEXICON E (TOPICAL) 0.0% OFF No-Gen ULTRAVATE LOTION (TOPICAL) 0.0% OFF No  Discussion: None  Kevin Izard made a motion to accept staff recommendations as presented. o Second – Michael Witkovsky o All members were in favor of the motion o Motion passes

Wisconsin Medicaid STIMULANTS AND RELATED AGENTS

Curr. Curr. PDL PDL COMMITTEE SECRETARY Brand Name MS Status Rec RECOMMENDATIONS STATE MODIFICATIONS MODIFICATIONS ARMODAFINIL (AG) (ORAL) 0.0% OFF No-Gen KAPVAY (ORAL) 0.0% ON Yes CONCERTA (ORAL) 10.6% ON Yes METADATE CD (ORAL) 0.0% ON Yes GUANFACINE ER (ORAL) 9.5% ON Yes-Gen METHYLPHENIDATE (ORAL) 6.5% ON Yes-Gen AMPHETAMINE SALT COMBO (ORAL) 12.5% OFF No-Gen FOCALIN (ORAL) 0.1% ON Yes FOCALIN XR (ORAL) 5.2% ON Yes DEXMETHYLPHENIDATE (ORAL) 1.6% ON Yes-Gen ARMODAFINIL (ORAL) 0.0% OFF No-Gen QUILLICHEW ER (ORAL) 0.3% ON Yes DEXMETHYLPHENIDATE (AG) (ORAL) 0.0% ON Yes-Gen MODAFINIL (ORAL) 0.2% OFF No-Gen VYVANSE CAPSULE (ORAL) 29.2% ON Yes NUVIGIL (ORAL) 0.1% OFF No QUILLIVANT XR (ORAL) 0.2% ON Yes VYVANSE CHEWABLE TABLET (ORAL) 0.0% ON Alternate VYVANSE CHEWABLE TABLET (ORAL) 0.0% ON Alternate DEXTROAMPHETAMINE TABLET (ORAL) 0.4% OFF No-Gen METHYLIN SOLUTION (ORAL) 0.0% ON Yes VYVANSE CHEWABLE TABLET (ORAL) 0.6% ON Yes APTENSIO XR (ORAL) 0.2% ON Yes AMPHETAMINE SALT COMBO ER (AG) (ORAL) 0.0% OFF No-Gen DAYTRANA (TRANSDERMAL) 0.2% ON Yes AMPHETAMINE SALT COMBO ER (ORAL) 0.0% OFF No-Gen METHYLPHENIDATE CD (AG) (ORAL) 0.1% ON No ADDERALL XR (ORAL) 13.3% OFF No DEXMETHYLPHENIDATE XR (AG) (ORAL) 0.0% OFF No-Gen ADDERALL XR (ORAL) 0.0% OFF Alternate DYANAVEL XR (ORAL) 0.0% OFF No METHYLPHENIDATE SOLUTION (AG) (ORAL) 0.1% ON Yes-Gen METHYLPHENIDATE ER (METADATE ER) (ORAL) 0.8% ON Yes-Gen ATOMOXETINE (AG) (ORAL) 2.0% ON Yes-Gen METHYLPHENIDATE SOLUTION (ORAL) 0.0% ON Yes-Gen ATOMOXETINE (ORAL) 1.9% ON Yes-Gen METHYLPHENIDATE CD (ORAL) 2.3% ON No-Gen PROCENTRA (ORAL) 0.0% OFF No-Gen DEXMETHYLPHENIDATE XR (ORAL) 0.0% OFF No-Gen DEXTROAMPHETAMINE CAPSULE ER (ORAL) 0.4% OFF No-Gen METHYLPHENIDATE ER (RITALIN LA) (ORAL) 0.4% ON Yes-Gen CLONIDINE ER (ORAL) 0.8% ON Yes-Gen METHYLPHENIDATE ER (CONCERTA) (AG) (ORAL) 0.0% OFF No-Gen METHYLPHENIDATE CHEWABLE TABLETS (ORAL) 0.1% ON Yes-Gen RITALIN LA (ORAL) 0.0% OFF No MYDAYIS ER (ORAL) 0.1% OFF No ZENZEDI (ORAL) 0.0% OFF No-Gen COTEMPLA XR ODT (ORAL) 0.0% OFF No DEXTROAMPHETAMINE SOLUTION (ORAL) 0.0% OFF No-Gen ADZENYS XR ODT (ORAL) 0.0% OFF No METHYLPHENIDATE ER (CONCERTA) (ORAL) 0.0% OFF No-Gen ADZENYS ER SUSPENSION (ORAL) 0.0% NR No EVEKEO (ORAL) 0.0% OFF No DEXEDRINE SPANSULE (ORAL) 0.0% OFF No METHYLPHENIDATE ER 72 MG TABLETS (ORAL) 0.0% OFF No-Gen METHAMPHETAMINE (ORAL) 0.0% OFF No-Gen

 Discussion: Rachel Currans-Henry stated that during closed session there was discussion about different ways to communicate changes to the Preferred Drug List to pharmacies and prescribers, particularly updates related to pediatric members.

The Committee also discussed the transition of Adderall XR from Brand Before Generic (BBG) to Brand Medically Necessary (BMN) in the second quarter of 2019. The Department is planning to publish multiple ForwardHealth Updates to ensure this change is clearly communicated over the next few months.

Michael Witkovsky asked if a prescription is written for Adderall, may a pharmacy substitute for the generic product without a new prescription. Alicia Walker responded that yes, the pharmacy could do such a substitution without further action. Rick Pope added that some pharmacies may have internal policies that do not allow substitution of medications without a new prescription.

 Michael Witkovsky made a motion to accept staff recommendations as presented. o Second – Robert Rohloff o All members were in favor of the motion o Motion passes